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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT kl .3 1601 E. HAZE_J AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 7 YEAR FROM DATE ISSUED'y *� (Complete in- Triplicate)' Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. This application is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the R41es and Regulations of the San Joaquin Local Health District. t -h Job Address AF fen 1,2=w A City;/NI.�IibT .9 Lot Size' ' PM Owner's Name //Q E?prt<., _3LW4=5 -Address &_,eZr1eJ6A Phone Contractor Address License No. Fhone" " - TYPE OF WELL/PUMPS 'NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ i "PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ __t_ `YO�HER ❑ DJSTANCE TO NEAREST: SEPTIC TANK `� SEWER LlyS� w DISPOSAL FLD. _ PROP. LINE FOUNDATION AGRICULTURE WELL -;'-- -OTHER WELL PITS/SUMPS INTENDED USE TYPE OF,WELL PfiOBLEM AREA CONSTRUCTION-SPECIFIGAFiONS ❑ Industrial ❑ Open Bottom ❑ MantecaIType Dia. of Well Excavation j i i Dia, of Well Casing ❑ Domestic/Private C1 Gravel Pack LlTr Tracy, of Casing _ Specifications a ❑ Public% ❑ Outer : 171Delta 3Deph of Grout Seal It ! Type of Grout ❑ Irrigations --Approx. Depth LJEastern S. acePeal Installed by Repair Work Done E Type of:Pump H.P. �� State Work Done '' Well Destruction ❑ Well Diameter Y Sealing Material (top 501 ti Depth V `� Filler Material",{Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION'D REPAIR/ADDITION DESTRUCTION C1 .(No septic system permitted if public sewer is ~[� ; f,T ' available within 200 feet.) " r �. Installation will serve Residence- ornmarcial_ Other Number of living units: Number of bedroom's f N Character of soil to a depth of 3 feet: 3 4A'1,by ,) t! P �; 7"1 ,_._Water table depth /PKG. SEPTIC TANK 71, Type/MfgCapacity{TRE TMENT PLT. ❑ �.-^ J /" -`Method of Disposal Dustance to-nga.rest: ' Well Foundation !°Property Line a c LEACHING LINE: Ll No. & Length of lines li Total length/size SC7 N FILTER BED Distance to nearest:. Wellpundation 7 Property Line 'F� 1 iNSEEPAGE PITS �`❑ Depth Size /Number SUMPS SUMPS ❑`\Distance to nearest: Well Foundation / Property Line DISPOSAL PONDS ❑ I hereby=certify that I have prepared,this application and that the,work will be done in accordance with San Joaquin county ordinances, state laws, and 4 rules and regulations of the San Joaquin Local Health District.f Home owne�rNor licensed agent's signrTture certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws-6f California."Contractor's hiring or sub-contracting signature certifies the following: "I certif�that in the performance of the work for which this permit is issued,I shall employ persons subject to workman's compensa- tion laws of California." The applicant must c II for all quire pections. Complete drawing on reverse sfide. Signed ' Title: Date: a t \ FOR DEPARTMENT USE ONLY _ II'' 7 { Applic8tion�Accepted by r Date ! Tr. Area 3 } Pit or Grout Inspection by Date Final Inspection by Date 1 e Additional Comments: r ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 ,, Applicant- Return all copies to: Environmental Healtl, Permit/Services'1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA.95201 # INFO FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY {-CK DATE PERMIT`NO. + EH 13-24(REV.1/85) �p } EH 1426 ' 9